The RCPCH service review determines that staffing numbers and competencies at The Countess were inappropriate for the acuity of the babies being cared for. In this episode, Michael and Peter discuss this issue and possible reasons for the increased acuity in 2015 and 2016. However, the discussion soon turns to the bigger question of why the consultants did not use the Child Death Overview Panel to report deaths as early as June 2015, and their concerns about them, as they should have done.